MRI Hip and Groin Pain
Dr JC Healy FRCP FRCR FFSEM Chelsea and Westminster Hospital
Honorary Senior Lecturer Imperial College The Fortius Clinic , London UK
Pelvic Overuse Injury • 5-6% athletic injury in adults • 10-24% athletic injury in children • lower limb dominated athletic activity football, rugby, running, ballet
• MRI global view bone and soft-tissue IV gadolinium MR arthrography
Bencardino,Palmer RCNA 2002;40:267
Aetiology : Groin pain
• Articular • Osseous/Tendo-osseous • Muscular • Paratendinous/Bursal
Articular injury • hip ligament tears • labral tears • femoroacetabular impingement • osteochondral injuries • transient bone marrow oedema
Intrinsic Hip Ligaments
Intrinsic Ligament Injury
• isolated ligamentum teres injury rare • subtle subluxation - rugby fall on flexed knee with hip abducted
• posterior acetabular fracture • only 5% diagnosed pre-arthroscopy
Anderson et al Am J Sports Med 2001;29:521 Erb Clin Sports Med. 2001;20:661 Rao et al Clin Sports Med 2001;20:791
Ligamentum teres injury
Extrinsic Hip Ligaments
Extrinsic Ligamentous Injury • iliofemoral ligament injury common following dislocation subtle hip subluxation - rugby
• early OA • arthroscopic capsulorrhaphy
Boutin, Newman MRI Clins NA 2003;11:255 Kelly et al Am J Sports Med. 2003;31:1020
Iliofemoral ligament injury
Labral tears • non-specific symptoms • predispose to OA • sport - repetitive direction change • MR arthrography >> conv MR sensitivity 90%; accuracy 91%*
• paralabral cyst - increases specificity
*Czerny et al AJR 1999;173:345
Paralabral cyst
Femoroacetabular impingement • hip flexion, adduction, internal rotation • abnormal head-neck morphology
pincer, cam, mixed • subcortical oedema or cyst formation • ant-sup labral tear • ant-sup acetabular cartilage abnormality
Kassarjian et al Radiology 2005;236 Siebenrock et al JBJS 2003;85:278
Femoroacetabular impingement
Ito et al JBJS 2001; 83:171 Schmid et al Radiology 2003;226:382 Siebenrock et al JBJS 2003;85:278
Cam-type
Femoroacetabular impingement
Osteochondral injuries
• repetitive microtrauma • subclinical shearing/impaction injury • subtle hip instability - contact sports • often superomedial femoral head
Weaver et al AJR 2002;178:973 Overdeck, Palmer Sem Musculoskeletal Radiol 2004;8:41
Osteochondral injuries MR arthrography
MR arthrography vs hip surgery • 40 patients : 2 readers sens 50-79%: spec 77-84% acc 69-78%: poor kappa
• good for high grade cartilage defects • poor for softening, fibrillation, flaps,
small loose osteochondral fragments
Schmid et al Radiology 2003;226:382
Transient Bone Marrow Oedema
• Self limiting bone marrow oedema and synovitis in the hip
• Osteopaenia and insufficiency fractures young males following sports injury Pregnancy, middle age F>M
• May be a continuum to iscahemic necrosis • Treated with biphosphonates to speed recovery
Osseous/Tendo-Osseous Injury
• osseous injury stress response/fracture
• tendo-osseous injury apophyseal injury enthesopathy tendon avulsion
Stress Fracture • 20% all injuries in sports related trauma • normal bone subject to abnormal forces • prox femur, pubic rami, sacrum • risk factors - female > male 1.5-3.5 : 1 - declining fitness with age
Anderson et al Am J Sports Med 2001;29:521
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Stress fracture • *340 - activity related hip/groin pain - 40% stress fractures - 60% proximal femur: 40% pelvis - incidence F > M
• plain films inadequate in early stress injury sensitivity 15% at diagnosis, 50% at F/U
• MRI gold standard specificity: MRI > bone scintigraphy
*Kiuru et al Eur Radiol 2003;13:605 Arendt, Griffiths Clin Sports Med 1997;16:291 Shin et al Am J Sports Med 1996;24:168
Stress Injury - MR classification • grade 1 - periosteal oedema STIR/T2 • grade 2 - bone marrow oedema STIR/T2 • grade 3 – marrow oedema on T1 and STIR/T2
• grade 4 - low signal fracture line - correlates with symptoms - useful prognosticator for rehab
Fredericson et al Am J Sports Med 1995;23:472 Yao et al Acad Radiol 1998;5:34
Tendo-osseous injury • developing skeleton - physis/apophysis stress response apophyseal avulsion
• mature skeleton - enthesis enthesopathy tendon avulsion tendon and bony avulsion
203 avulsion injuries in adolsecent athletes Rossi, Dragoni Skeletal Radiol 2001;30:127
Ischial tuberosity AIIS ASIS pubic symphysis
ASIS
AIIS
Osteitis pubis - Athletic pubalgia • chronic athletic groin pain • insidious onset 6-12 weeks • common in football
- incidence 14-28% in soccer players - 10% acute :18% chronic injuries - parasymphyseal stress response - cleft effusion - adductor tendinopathy
Kavanagh et al Semin Muscoloskeletal Radiol 2006;10:197;23:472 Robinson, English Semin Muscoloskeletal Radiol 2011;15:14
Muscle injury
• common in football • iliopsoas, gluteus, pectineus, hip rotators • frequently present with hip/groin pain • tend to rehabilitate quickly <2/52wks • occasionally develop chronic symptoms heterotopic ossification
Iliopsoas
Pectineus
Quadratus femoris
Tendon/Bursal Overuse Injury
• overuse/impingement injury • bursitis/paratendinitis/tendinopathy - iliopsoas - iliotibial tract/gluteus - common hamstring
• audible/palpable snapping +/- pain snapping hip syndrome
Overdeck, Palmer Sem Musculoskeletal Radiol 2004;8:41
Iliopsoas bursitis
Iliopsoas paratendinitis
common hamstring enthesopathy
Hip and groin pain Summary
• Articular injury • Osseous/Tendo-osseous injury • Muscular injury • Paratendinous/bursal injury
Summary MR Imaging - Technique
• non-specific groin pain • extra-articular abnormality • cor/ax T1 and STIR/VEfs • cor/ax T1 fat sat post gad
Summary MR Imaging - Technique • internal hip derangement • effusion SFOV cor/ax oblique VE fat sat
• no effusion MR Arthrography cor/ax oblique/sag oblique T1 fat sat